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2014-05-15

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Examples of the operationalization of the aviation world.

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Examples of the operationalization of the aviation world.

Some time ago, it happened that the flight mechanic, but the command of the commander of the ship "RUD zero - the screws - from the stop", removed the flaps in place to remove the propellers from the stop, which was supposed to be due to the similarity of the procedures for cleaning the flaps and removing the propellers from And the proximity of the corresponding controls.There followed a proposal to change the position of one of the controls to minimize similarity: it was decided to swap the control element with propellers After the proposal was practically implemented, a ten-year operational experience showed that, in fact, errors in mixing flap and rotor controls had disappeared, but there were errors in the entanglement of the propellers and chassis controls (these errors were considered above ), That is, the implementation of the proposal led to the migration of the error.The situation can be explained as follows: The introduced change did not affect the status of the procedure for removing the screws from the stop. And since the control elements of the chassis and propellers have similar characteristics, it is quite natural occurrence of cases of their unconscious entanglement.

Note that means especially designed to prevent the entanglement, while if they do not change the status of the procedure is often not effective, and furthermore, may provoke an error.

The following example illustrates this thesis. During the training flight, the mechanic, releasing the chassis, looked at the chassis position indicator. At this time, the right engine refused (it was flown for training purposes by the inspector). The commander of the ship gave the command to turn off the right engine. To turn it off, it is necessary to turn, in particular, the corresponding stopcock. ('The top cranes of the right and left engines are located next to each other and are closed by each of their safety caps, there is a special partition between them.) By going to turn off the right engine, but continuing to look at the chassis position indicator, the mechanic raised the caps of both stop-valves with the right thumb, Both because, as we have already said, at this time he released the chassis and did not become distracted by the discrimination of the caps. It should be taken into account that the flight was not a trip, but a training flight and for the flight engineer When the caps were raised, the hand mechanically fell down and the thumb fell on the partition separating the two stop valves.The partition had a sloping surface that provoked involuntary movement.The movement of the hand occurred with the inclination of the hand in The left side, because the fingers bent into a fist interfered horizontally with the movement of the left stop-cock, the left engine was stopped and turned off. Thus, the partition specially designed to distinguish the stop valves, in this case, contributed to the occurrence of an error.